Background: Over a decade, postoperative complications in patients undergoing major head and neck surgery with free flap repair, in a single UK institution, have been prospectively evaluated. This period has coincided with healthcare system, as well as local quality improvement (QI) initiatives, targeted at reducing adverse events. This article chronicles that experience.Methods: Between August 2009 and July 2020 prospective data on postoperative complications in a cohort of patients undergoing major head and neck surgery requiring free flap repair was collected supplemented by healthcare record review. Outcomes metrics comprised major complications, wound complications, pulmonary complications, flap failures and unscheduled return to the operating theatre in the postoperative period, and 30 day or in-hospital mortality. The study period was divided into 3 time periods to gauge longitudinal changes.
Results:The study population comprised a total of 1,112 patients. The proportion of patients undergoing surgery for a laryngopharyngeal defect, proportion who had undergone prior major head and neck surgery, and proportion who had undergone previous radiotherapy all increased in the later time periods. Changes in the selection of flap donor sites occurred with a shift away from rectus abdominis and vascularised iliac crest flaps and increasing use of anterolateral thigh and subscapular system flaps. Tracheostomy was avoided in a higher proportion latterly and recourse to perioperative blood transfusion declined. There was a significant reduction in wound complications in (P<0.001) in the latest time period. No reduction in the rate of major complications, pulmonary complications, flap failures, and unscheduled return to the operating theatre occurred over time. Thirty-day and in-hospital mortality combined was 0.9%.
Conclusions:Postoperative complications in patients undergoing head and neck free flap surgery are prevalent and recalcitrant. Single institutions acting independently are likely to find it difficult to make rapid and dramatic improvements. Collaborative QI methodologies, across healthcare systems, should be adopted using comparative data to identify optimal care practices and rapidly generalising the findings.